| Approach to Infertility
a disorder that affects 10 - 15% of couples. The standard and time-honored
definition of infertility is "failure to achieve a pregnancy
after one year of unprotected intercourse". However this standard
definition may be inadequate for all patients. For example couples
with obvious problems and older couples may need to be considered
for earlier evaluation. When counseling infertile couples, it is
also useful to remember that the chance that a pregnancy will happen
every month, in normal couples is only about 25% and that most treatment
options in infertility do not exceed this pregnancy rate.
The basic evaluation of an infertile
couple begins with a good history and physical examination. Obtaining
a sexual history helps identify any sexual dysfunction, which the
couple may not volunteer. Following this one needs to do a semen
evaluation, assess tubal patency and assess ovulation.
| Evaluating the male factor
The semen analysis
is the gold standard for the evaluation of male infertility. It
is a relatively easy and inexpensive test to obtain. While ordering
a semen analysis, it is important to ensure that there is abstinence
for a period of 4 days prior to the test. It is best that the collection
is done at the place of testing. If this is not possible then the
sample must reach the lab within 30 - 60 minutes of collection.
In the event that a condom is required for collection, one without
spermicide must be used. These are special condoms and not ones
that are usually avaiablebe. If an abnormal semen analysis is found
then the test must be repeated at least 4 weeks after the first
test. If the abnormal result persists then consideration for referral
to an urologist must be made. An anatomical and endocrine assessment
needs to be made. Though various treatment modalities have been
tried, in general hormonal treatment does not improve the fertility
| Evaluating the female
The methods of
assessing ovulation vary from basal body temperature charts to hormonal
assays to ultrasound assessment of follicular growth. Basal body
temperature charts are inexpensive but are ineffective in prospectively
predicting ovulation. Mid-luteal phase progesterone is simple for
patients to obtain and give a general assessment of ovulation and
adequacy of luteal phase. The disadvantages are that the levels
vary with different cycles and it does not give any assessment of
the endometrium. Endometrial biopsies in the late luteal phase were
considered the gold standard for the evaluation of luteal phase.
Unfortunately the interpretation may not be consistent and it needs
to be done twice to establish luteal phase inadequacy. This becomes
painful and expensive.
Serial ultrasounds and follicular
tracking is very predictive of ovulation and also helps assess endometrium
but is expensive. Doing the monitoring on just 2 - 3 days to helps
establish growth of the follicle and document ovulation rather than
scans on done every day or every alternate day will help decrease
the total number of scans done and also decrease the inconvenience
for the patient.
There are many
ways of doing an uterotubal assessment. These include an HSG, laparoscopy,
Hysteroscopy and Sonosalpingography. The age old outpatient "tube
testing" with the Rubin's canula may still have a very limited
place in certain situations where cost primarily becomes an issue
or if a more definitive test like a laparoscopy is consciously postponed
while assessing ovulation or the male factor.
The HSG is the initial choice for
uterotubal assessment. This provides a screening for the endometrial
cavity and also assesses tubal patency. Although there may be artifactual
filing defects or tubal spasm, the HSG remains critical in the initial
evaluation of an infertile woman.
A laparoscopy is an extremely useful
test in the sense that it helps evaluate the adnexae along with
documenting tubal patency. It helps identify and treat endometriosis
and adhesions, which may be contributing to the infertility. It
is inevitably done later in the course of any infertility work up.
It may be useful to combine a hysteroscopy with a laparoscopy if
assessment of the uterine cavity is also needed in some patients.
More recently the sonohysterogram
and the sonosalpingogram are increasingly used. These are relatively
non-invasive ways of testing for tubal patency.
| PCT is there a role?
The post coital
test is a method of assessing the cervical mucus (as an indictor
of ovulation) and the sperm survival and motility. Today, most people
consider it a redundant test since IUI is the treatment option resorted
to earlier than later in most situations. Still it has place in
certain situations and also helps to give us an idea about sexual
dysfunction in a couple.
| Handling anovulation
The initial evaluation
of anovulation includes a TSH and a prolactin level. In older women
a FSH value is also important to look at ovarian reserve. If these
are normal then treatment is initiated with clomiphene citrate,
starting with a dose of 50 mg between day 2 - 5 of the cycle and
then increasing if there is no response. At least the first cycle
of clomiphene needs to be monitored to evaluate response. In
higher doses it is important that every cycle is monitored by ultrasound.
In women who have an elevated TSH
or Prolactin, appropriate work up and treatment will usually result
in anovulation. Some times after correction of the underlying problem,
clomiphene may be needed to induce ovulation.
|What do we do with clomiphene failure?
If there is no
response to clomiphene, then one needs to assess presence or absence
of insulin resistance. Insulin resistance is also tested earlier
in hyperandrogenic women. If there is a suggestion of insulin resistance,
then there may be value in considering therapy with metformin at
a dose of 500 mg three times a day to decrease the insulin resistance.
This may be used in addition to clomiphene in such women.
The alternate therapy in these women
( or in women who do nto respond to Clomiphene + metformin) is to
use gonadotropins. The dosage of gonadotropins required to induce
ovulation may vary from patient to patient. It is mandatory that
all gonadotropin cycles be monitored with ultrasound.
Anovulatory women who need gonadotropins
must have tubal patency assessed before therapy is initiated. Given
the cost of therapy, if there were no pregnancy in a 2-3 cycles
then it would be worthwhile to consider IUI in such patients.
| Managing male infertility
options in the presence of significant abnormality in the semen
analysis would be intrauterine insemination, donor insemination
For optimising success with IUI, at
least 1 million sperms need to be inseminated. In oligospermic samples
this may be achieved by combining 2 samples. Superovulation increases
the chances of pregnancy with IUI.
While offering donor insemination,
it is important to stress to the couple that success rates may vary
from 5 - 20 %. It is important to maintain anonymity, match donors
and ensure effective screening for infections and disease.
| Offering ART
ART is done in the following situation:
ovarian failure - (donor oocyte IVF)
It cannot be emphasised enough that
couples must be counselled well prior to IVF or ICSI and be given
realistic expectations of outcome.
|When do we stop?
| We have to consider stopping therapy
if there is no successful outcome after 3 or more years of treatment,
if all treatment options are exhausted or if cost becomes a constraining
In these situations
providing emotional support and directing to think of adoption may
be more realistic options.
is an emotional and social problem as much as it is a medical problem.
Couples must therefore be approached gently, treatment planned rationally
and care taken to not perpetuate myths.